Results Postoperative pain was found to be significantly lower in the local anesthesia group compared to the control group (VAS 3 ± 1.9 vs 6.4 ± 1.8, p less then 0.001; PHHPS 0.9 ± 0.8 vs 1.62 ± 0.82, p less then 0.001). As a result of this, opioid drug use was significantly lower in the local anesthesia group compared to the control group (0 (0 - 4) vs 1 (0 - 8), p less then 0.001). Mechanical ventilation time, intensive care unit and hospital stay duration, and development of atelectasis were significantly lower in the local anesthesia group. In terms of the development of atrial fibrillation, no significant difference was found between the groups. Conclusion Parasternal continuous local anesthetic infusion reduces postoperative opioid use and speeds up hemodynamic healing by preventing possible side effects of opioids. It is a simple and effective method in the treatment of postoperative pain due to median sternotomy.Superior mesenteric artery (SMA) syndrome has been described in medical literature as a rare cause of duodenal occlusion.  https://www.selleckchem.com/products/bismuth-subnitrate.html  It has a varied presentation, with distressing gastrointestinal symptoms such as nausea, abdominal pain, and further weight loss. Several conditions contribute to duodenal obstruction in SMA syndrome. We present a case of SMA syndrome in a patient with malignant breast cancer who presented with sudden onset of severe nausea and voluminous vomiting. Various imaging studies revealed a distended proximal intestine with a transition point in the third part of the duodenum. The patient was managed conservatively with nasogastric decompression and fluid electrolyte management, leading to symptomatic relief.Complete heart block (CHB) in a young patient is a rare phenomenon necessitating an extensive workup to identify the etiology of conduction disturbance. Radiotherapy of the thorax is a known risk factor for cardiomyopathy; however, CHB is a rare complication. Here we present a case of a 46-year-old man who presented with CHB and was found to have significant cardiac fibrosis and calcification of the mitral valve annulus. His management required a multidisciplinary and multimodality approach to be able to identify childhood radiation as the cause of cardiomyopathy and establish a personalized management strategy with cardiac resynchronization therapy defibrillator. This case highlights radiation therapy as an important cause of cardiac conduction abnormalities even decades later, and the importance of extensive search for other reversible etiologies using the multimodality approach.Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause a hypercoagulable state that can complicate the management of patients presenting with acute myocardial infarction (MI). We present the case of a patient with coronavirus disease 2019 (COVID-19) with ST elevation MI who was treated with percutaneous coronary intervention and stenting to the left circumflex artery. He was treated appropriately with anticoagulation with appropriate activated clotting time. However, the coronary angiogram course was complicated with heavy thrombosis that involved the left circumflex artery and the left anterior descending artery. Physicians are urged to suspect heparin resistance in COVID-19 patients, particularly if those patients have venous thromboembolism or acute coronary syndrome while taking heparin.MR-guided adaptive radiation therapy (RT) is emerging as an integral treatment modality for certain applications and is poised to become an exciting opportunity for greater treatment precision and personalization. However, this is still a relatively nascent technology and only a few institutions and programs have access to this technology for clinical use and trainee education. To increase the diversity of elective offerings and improve the understanding of an MR-guided radiotherapy program, we initiated a unique MR-guided radiotherapy elective rotation for radiation oncology residents. During a representative four-week rotation, 21 simulations were completed by the resident on service. A plurality of simulations were for pancreas stereotactic body radiation therapy (SBRT; 48%) and a majority (71%) of simulations were for adaptive treatments. Additionally, 74 adaptive fractions were completed during this month, of which a significant majority (74%) were for pancreas SBRT. Of the non-adaptive fractions, the majority were for prostate SBRT and intensity-modulated radiation therapy (IMRT). Although many programs may offer training in some aspects of MR-guided radiotherapy as trainees rotate through certain disease sites, we hope this may serve as a blueprint to encourage programs with this technology to fully embrace training in essential competencies related to MR-guided radiotherapy. MR-guided radiotherapy has unique challenges that trainees need to understand to deliver treatment safely geometric uncertainty, MRI to RT isocenter, and uncertainties with voxel size/tracking.Coronavirus disease 2019 (COVID-19) is a contagious disease that has a potential of causing cardiovascular illness. Cardiac outcomes of COVID-19 mainly include acute coronary syndrome, heart failure, and left ventricular dysfunction. However, pericardial involvement is very rare. Here, we present a case of pericarditis and pericardial effusion in a known hypertensive COVID-19 patient. Our case was a diagnostic dilemma as the literature review mentioned that cardiovascular manifestations are mostly reported in symptomatic and critically ill patients of COVID-19. However, this patient has no viral respiratory illness, and is otherwise healthy.The majority of the perioperative arrhythmias in patients undergoing cesarean section under spinal anesthesia are benign. We report a case of a 30-year-old full-term parturient with a history of an uneventful previous cesarean section. She had no preexisting comorbidities. She subsequently underwent another emergency cesarean section three years later due to abdominal pain and scar tenderness indicative of impending rupture. Two hours after an uneventful surgery, the patient developed epigastric pain with a prolonged PR interval (280 ms) and intermittent second-degree AV block with two consecutive blocked P waves, which was consistent with Mobitz type II second-degree heart block (atypical Wenckebach block). However, she remained hemodynamically stable throughout. Serial electrocardiogram (ECG) did not demonstrate any evidence of ST-T wave changes, and normal troponin I and echocardiography excluded myocardial ischemia as a potential cause for the arrhythmia. Normal serum electrolytes and the resolution of the sensorimotor block caused by the spinal anesthesia excluded other known causes for such ECG changes.